When Record Keeping Goes Wrong

Record problems are patient-safety and governance issues, not merely administration. Missing, inaccurate or misleading entries can lead to poor clinical decisions, incorrect referrals, medicine errors, safeguarding failures, inadequate complaint responses and loss of public trust. Dental nurses should feel able to raise concerns when a record issue could affect care.

Some record errors are minor and should be corrected. A harmless spelling mistake that does not change meaning is unlikely to cause harm. However, a missing allergy, an entry placed on the wrong patient file, unrecorded consent concerns, altered notes, omitted referrals or incorrect aftercare instructions can create real risk.

Speak up when you notice

• A record appears attached to the wrong patient.
• Important medical-history information is missing or out of date.
• A record states advice was given when it was not.
• Someone asks you to use their login or to change an entry without an appropriate reason.
• A missing or incorrect record could affect treatment, follow-up, safeguarding or a complaint response.

Simple, direct phrases work when raising a concern: "Can we pause and update the record before treatment starts?", "I am worried this is on the wrong patient record", "I cannot record that I witnessed a discussion I did not hear", and "This needs to be corrected through the proper process".

What your practice should have in place

Professional record keeping includes speaking up when a record is missing, inaccurate or misleading.